C h a p t e r 1 6

International Trends in Geropsychology

Nancy A. Pachana

Fish discover water last. initiatives are viewed and used overseas, which is —Ethiopian proverb more difficult to do if one is within the large expanse of U.S. research and practice. Despite the Aging as a discipline, as an area of health and eco- presence of a rich world of geropsychology research nomic interest, and as a sociological and political and practice beyond U.S. borders, it is sometimes phenomenon is gaining wider recognition and grow- difficult to see what is all around us—hence the ing in scope and prominence. This is true in the quote at the beginning of this chapter. developing world as well as in the developed world. This chapter aims to give the reader a broad Aging as an experience is universal and yet deeply overview of in the interna- personal for individuals. The experience of aging is tional area. The requisite sections on demographics shaped by the societies and communities in which and cross-national research are augmented by people live and in turn has an impact on policies and discussions of how geropsychological and, indeed, institutions at local, national, and international levels. gerontological theory and practice vary across coun- Clinical geropsychology as a discipline has rela- tries and what the emerging issues are for the field, tively recent beginnings and in some countries including training imperatives. I highlight a selec- remains relatively underrepresented in terms of both tion of initiatives directed at a broad spectrum training and presence in the of older adults, from healthy aging programs to workforce (Pachana, 2012). In the face of changing programs aimed at those with disorders such as demographic realities, however, interest in clinical and . The chapter concludes geropsychology as a discipline, as an area of with a rationale for how clinical geropsychology research, and as a profession is increasing benefits from increasing cross-national fertilization internationally. with respect to knowledge gained through research This chapter is part of a handbook aimed at a as well as innovations springing from the interna- U.S. audience. A description of international gero- tional geropsychology community. psychology should be read in this context not as a Copyright American Psychological Association. Not for further distribution. description of the other, in that it is examining what lies outside U.S. borders, but rather as a global per- DEMOGRAPHICS spective on the field, the United States being an intrinsic part of that global arena. Many important Internationally, the proportion of people older than legislative, regulatory, research, and clinical initia- age 65 is increasing dramatically. This is, of course, tives already benefit from collaborations with U.S. the standard opening line to many a lecture or text geropsychologists, and many more such efforts are on aging. Global statistics available from the World less well known and could inform and inspire. In Health Organization (WHO) and the United Nations addition, there is utility in seeing how U.S. (UN) are illuminating in their depiction of how the

http://dx.doi.org/10.1037/14458-017 APA Handbook of Clinical Geropsychology: Vol. 1. History and Status of the Field and Perspectives on Aging, 421 P. A. Lichtenberg and B. T. Mast (Editors-in-Chief) Copyright © 2015 by the American Psychological Association. All rights reserved. Nancy A. Pachana

world is changing in the face of changing demograph- countries and even within countries. For example, ics. For example, Figure 16.1 makes the powerful in Australia the trend is for older people to seek out point that globally, for the first time in history, the a more congenial retirement or preretirement by number of people younger than age 5 will be out- moving away from urban areas, colloquially known stripped by the number of people age 65 and older as a “sea change” or a “tree change,” depending on (UN, 2010). It is notable that the number of older proximity to coastal or rural areas (Australian Insti- adults is rising exponentially, with a projected tute of Health and Welfare, 2007). The sudden 1.5 billion people older than age 65 expected by popularity of such areas for older adults has put 2050, with much of this growth in the aging pressure on systems and in part driven population experienced by developing countries the development of e-health innovations in this (WHO, 2011). country, including in long-term care facilities (Gray However, it is important to remember that popu- et al., 2012). In other countries, such as China, the lation aging is not occurring at the same speed in migration patterns are for people, including some all locations across the globe—and a rapidly aging older people, to migrate from more rural areas to demographic puts greater stress on infrastructure urban areas; in fact, by 2050, almost a quarter of and social policy and may require shifts in thinking urban populations in less-developed countries will about issues such as retirement age, provision of be older than age 60, whereas in developed coun- long-term care, and health care delivery systems. tries, 80% of older people already live in urban areas For example, it took France nearly 120 years to go (UN Population Fund, 2007). The greater mobility of from 7% to 14% of its population being age 65 and older adults as well as their increasing numbers has older (which occurred in 1980); Korea will achieve implications for health and mental health care ser- that same milestone in less than 20 years (starting vices and service delivery. from 2000), making it one of the fastest aging coun- The greater mobility of people at all ages is tries in the world (WHO, 2011). Such swift change reflected in the number of people living in countries will have many specific implications for this nation, who were not born there. Such populations may but such aging trends can be seen in a number of reflect the movements of refugees, immigration for Copyright American Psychological Association. Not for further distribution.

Figure 16.1. Young children and older people as a percentage of global population: 1950–2050. From World Population Prospects: The 2010 Revision, 2010, New York, NY: United Nations. Copyright 2010 by the United Nations. Reprinted with permission.

422 International Trends in Geropsychology

better economic opportunities (seen most recently in nations to respond. Neurocognitive disorders response to the global financial crisis), parents mov- including Alzheimer’s disease and other ing to join children who have relocated overseas, are one such example. By 2050, estimates are that and movement to enjoy retirement in another coun- 115 million people will live with dementia (Alzheim- try. This has implications for the make-up of older er’s Disease International, 2009). The implications populations within countries and, by extension, their for the developed and the developing worlds differ, health and mental health, as well as social, needs as illustrated graphically in Figure 16.2. and concerns. For example, in Canada older Chinese Clearly, the trends illustrated in Figure 16.2 have Canadians have twice the prevalence of depressive infrastructure and health and mental health work- symptoms as the general older Canadian population force implications. Worldwide, the current number (Lai, 2000). Similar higher prevalence rates of of people estimated to be living with Alzheimer’s depression among older first-generation immigrants disease and dementia stands at between 27 million have been found in Europe (Aichberger et al., 2010). and 36 million (WHO, 2011), with increasing finan- By 2021, more than 30% of Australia’s older popula- cial and social costs. These costs are not distributed tion will have been born outside Australia (Depart- equally. Two thirds of people with dementia are esti- ment of Health and , 2012). This rise in the mated to be living in the developing world, where number of people from culturally and linguistically access to care is underdeveloped (WHO, 2011). diverse backgrounds has implications in Australia for Even research and research dollars track these dis- the provision of culturally appropriate care services crepancies; witness the 10/66 Dementia Research and information, and it requires a workforce that has knowledge of the intersection of aging, cultural, and health and mental health issues, particularly in nurs- ing home environments (Department of Health and Ageing, 2012). Improvements in living standards, health care, reduced infant mortality, and medical advances both in decreasing mortality from acute illnesses and greater symptom control and in reduced mortality from chronic diseases have led to globally increased longevity. Globally, the number of individuals older than age 85 is projected to increase by 351% between 2010 and 2050, compared with a 188% increase in those 65 and older and a 22% increase in those younger than age 65 (WHO, 2011). Also, between 2010 and 2050 the global number of centenarians is projected to increase 10-fold (WHO, 2011). Absolute increases in the number of people of advanced age have several implications for geropsy- Copyright American Psychological Association. Not for further distribution. chology, including ensuring that diagnostic, assess- ment, and intervention strategies have relevance and empirical support for this age group. It is also imper- ative that trainee psychologists be comfortable inter- Figure 16.2. The growth in numbers of people acting with clients who are several cohorts removed with dementia in high-income countries and low- and in experience and therefore that this be reflected in middle-income countries: 2010–2050. From World training programs (Laidlaw & Pachana, 2009). Alzheimer’s Report, 2010, 2010, London, England: Alzheimer’s Disease International. Copyright 2010 by Finally, specific age-related illnesses may have a Alzheimer’s Disease International. Reprinted with differential impact on the capacities of various permission.

423 Nancy A. Pachana

Group (http://www.alz.co.uk/1066). The name of In individuals older than 60 globally, noncommuni- this organization refers to the fact that 10% or less of cable diseases account for more than 87% of disease population-based research on dementia has been burden. carried out on the two thirds (66%) of people with Another key WHO document on aging is the dementia living in low- and middle-income coun- Knowledge Translation Framework for Health and tries. Finally, conceptualizations of what dementia Ageing (WHO, 2012), which proposes a framework is, what the behaviors of people with dementia to assist with translating research on aging into pol- might mean, and what need are viewed in icy and practice. The report points out that without very different ways across societies (Alzheimer’s a local appreciation for and desire to link aging pol- Disease International, 2012). For example, in some icy and practice to the research evidence, such trans- Asian and other cultures around the globe, dementia lation will not occur. It points out the importance is thought of as a psychiatric condition (rather than of “push” and “pull” efforts by researchers. Push as a progressive neurological condition), and fur- efforts by researchers help bring the relevant evi- thermore it is a condition that may bring shame on dence bases to the attention of policymakers; pull the family if its existence is widely acknowledged. efforts are aimed at making it easier for policymak- These views are complicated when one factors in the ers to identify and obtain the relevant research number of migrants from different cultures living in evidence. countries with often very different views and tradi- With respect to policy, WHO’s (2002a) Active tions of conceptualizing age and interacting with Aging Policy Framework has been influential in shap- older adults in general and family in particular. ing the conversation around healthy and successful aging. Active aging is defined in this report as “the process of optimizing opportunities for health, par- GLOBAL AGING INITIATIVES AND MAJOR ticipation and security in order to enhance quality of INTERNATIONAL POLICY DOCUMENTS life as people age” (p. 12). The word active was cho- Both the UN and WHO have a variety of statements, sen to reflect the continuing participation of older policies, and initiatives with respect to aging. In adults in the social, economic, cultural, spiritual, addition, various national and international peak and civic affairs of their communities, which is bodies and organizations have published toolkits, thought to contribute to aging well. Such active par- information, and resources about mental health in ticipation is thought to benefit health, with health later life. A brief selection of prominent examples of being defined according to the WHO definition, these follows. which encompasses physical, mental, and social In 1991, the UN adopted a set of Principles for well-being rather than merely the absence of illness. Older Persons, recommending that all member gov- Interdependence and intergenerational solidarity are ernments incorporate these principles into programs also suggested as important for active aging, accord- directed at their older citizens. The 20 principles ing to this WHO framework. The WHO model pro- were specifically designed to “add life to the years poses six determinants of active aging embedded that have been added to life” and are summarized in within two overarching determinants of gender and Appendix 16.1. culture: (a) health and social service determinants Copyright American Psychological Association. Not for further distribution. In 2011, WHO published its report on global (health promotion and disease prevention, curative health and aging in partnership with the U.S. services, long-term care, mental health services); Department of Health and Human Services. This (b) behavioral determinants (tobacco use, physical report has a particular emphasis on health in later activity, healthy eating, oral health, alcohol, medica- life from a global perspective. Trends such as the tions); (c) personal determinants (biology and increasing burden of chronic noncommunicable genetics, psychological factors); (d) physical deter- diseases on middle- and low-income countries minants (physical environments, safe housing, falls, (vs. communicable, maternal, perinatal, and nutri- clean water, clean air, safe foods); (e) social determi- tional conditions as well as injuries) are discussed. nants (social support, violence and abuse, education

424 International Trends in Geropsychology

and literacy); and (f) economic determinants The International Association of (income, social protection, work). and is concerned with gerontological Recently, several research groups have attempted research and training globally (http://www.iagg. to provide a stronger empirical evidence base for the info). It has a close consultative relationship with WHO (2002a) determinants of active aging. Buys the UN and WHO. The association hosts a world and Miller (2011) and Paúl, Ribeiro, and Teixeira congress every 4 years and hosts a series of educa- (2012) from Portugal have all used large samples to tional courses, including master classes on topics in attempt to verify the factors proposed in the WHO aging. The International Association of Gerontology model; all of these studies have come up with factors and Geriatrics supports two research collaborative that differ from the proposed WHO model to a networks: The Global Aging Research Network is greater or lesser extent, pointing to the need for dedicated to basic sciences and biological, behav- further cross-national research in this arena. ioral, and clinical gerontology and the Global Social Finally, the WHO (2007) age-friendly environ- Initiative on Aging helps foster collaborations ments program is aimed at positively affecting the around societal and population aspects of aging. health and well-being of older adults by ensuring Finally, the International Psychogeriatric Associ- that the physical and social aspects of their living ation is concerned with promoting better mental environments support their needs. Eight dimensions health for older people (http://www.ipa-online.net). of the living environment are targeted: the built envi- The association is a multidisciplinary organization ronment, transport, housing, social participation, with more than 60 member organizations globally. respect and social inclusion, civic participation and Special interest groups within the International Psy- employment, communication, and community sup- chogeriatric Association include a special interest port and health services. To foster and share infor- group for psychologists. The association hosts mation gained by participation in the program, the annual conferences and has a particular focus on WHO Global Network of Age-Friendly Cities and cross-national information sharing with respect to Communities was established. Communities in the mental health, particularly with respect to the devel- program range from very large cities (New York City oping world. It has also developed a well-respected and London) to relatively smaller cities (Melville, set of resources designed to help clinicians with an Western Australia, Australia, population 93,000). interest in behavioral and psychological symptoms This guide is informative for anyone wanting specific of dementia, The Complete Guides to Behavioral and knowledge about avenues of potential improvement Psychological Symptoms of Dementia (International to the living spaces older adults inhabit. Psychogeriatric Association, 2010). This series Several multidisciplinary international bodies includes three resource guides—a specialist’s guide, have a primary focus on aging more generally or a primary care physicians’ guide, and a nurses’ guide mental health issues in particular and are worth (for inquiries, contact [email protected]). noting. The first is the International Federation on Aging (http://www.ifa-fiv.org/about), an amalgama- NATIONAL AND CROSS-NATIONAL tion of organizations including nongovernmental RESEARCH ON AGING organizations; corporate, government, and academic Copyright American Psychological Association. Not for further distribution. bodies; and individuals with the purpose of sharing Several prominent longitudinal and cross-national information and influencing policy. The Interna- studies have provided valuable data on a range of tional Federation on Aging has campaigned for the topics important to aging, including health, mental rights of older people and hosts biannual global con- health, well-being, and economic and social factors. ferences on aging. The federation has a wide range A recent review of such longitudinal datasets on of resources on elder abuse that may be of interest aging pointed to their great contributions to both to clinicians, including a toolkit on increasing national policy planning and cross-national compar- awareness of elder abuse among adolescents (http:// isons of health outcomes with respect to the under- www.ifa-fiv.org/elder-abuse). standing of aging populations and their societal

425 Nancy A. Pachana

implications (Kaiser, 2013). Increasingly, datasets this demographic group is the fastest growing one are also focusing on the oldest old because they are across older cohorts (Ritchie, 1998). a fast-growing population; their high visibility in Such longitudinal and centenarian research pro- Europe in particular has led to much research on grams are large and expensive. Pooling or harmoniz- this group (for an excellent summary, see Paúl, ing data between such studies allows for maximal 2007). Such aging datasets and the research groups utility gained from such projects. Two examples of that coordinate them are also increasingly engaging such work are the Dynamic Analyses to Optimise in cooperative research studies, and new longitudi- Ageing study in Australia (http://dynopta.anu.edu. nal studies may explicitly look to existing longitudi- au) and the International Centenarian Consortium nal studies and response frameworks in assisting (https://www.publichealth.uga.edu/geron/research/ with organization and with an eye to future analytic intl-centenarian-study). Dynamic Analyses to Opti- collaborations. mise Ageing draws together data from nine Austra- The WHO itself coordinates an ambitious longi- lian longitudinal studies of aging for a combined tudinal study on aging, the Study of Global AGEing pool of more than 50,000 participants; exploring and Adult Health (Kowal et al., 2012), which col- key incidence rates and risk factors for health out- lects data on adults older than age 50, including a comes in older Australians is a prime focus of the smaller comparison sample of younger adults ages study. The International Centenarian Consortium 18 to 49, from a core group of nationally representa- links a number of studies of centenarians across the tive samples in six countries: China, Ghana, India, globe. These and similar collaborations allow for the Mexico, Russian Federation, and South Africa. examination of the impacts of aging policy and plan- Other notable longitudinal studies globally are ning across different countries. included in Exhibit 16.1; Exhibit 16.2 contains a list With respect to cross-national research, possibili- of centenarian studies. Centenarian studies in par- ties of interesting natural experiments also exist ticular may yield important information, given that with respect to naturally occurring variations in key

Exhibit 16.1 Selection of Prominent Longitudinal Studies of Aging

Australian Longitudinal Study on Ageing http://www.flinders.edu.au/sabs/fcas/alsa Berlin Aging Studies http://www.mpib-berlin.mpg.de/en/research/ lifespan-psychology/projects/the-berlin-aging-studies-base China Health and Retirement Longitudinal Study http://online.wsj.com/public/resources/documents/charls0530. pdf English Longitudinal Study of Ageing http://www.ifs.org.uk/ELSA Health and Retirement Study http://hrsonline.isr.umich.edu Korean Longitudinal Study of Ageing http://www.kli.re.kr/klosa/en/about/introduce.jsp Longitudinal Ageing Study Amsterdam http://www.lasa-vu.nl/index.htm

Copyright American Psychological Association. Not for further distribution. Longitudinal Aging Study in India http://www.hsph.harvard.edu/pgda/LASI/about.html New Zealand Longitudinal Study of Ageing http://nzlsa.massey.ac.nz Nordic Research on Aging Study http://www.jyu.fi/liikunta/tervtiede/NORA Seattle Longitudinal Study http://www.uwpsychiatry.org/sls Singapore Longitudinal Aging Study no website Survey of Health, Ageing and Retirement in Europe http://www.share-project.org Swedish Adoption/Twin Study of Aging http://ki.se/ki/jsp/polopoly.jsp?d=13903&a=30148&l=en Swiss Interdisciplinary Longitudinal Study on Oldest-Old http://cigev.unige.ch/publications/abs2001clespds_en.html Victoria Longitudinal Study http://www.ualberta.ca/~vlslab World Health Organization Study on Global AGEing and Adult http://www.who.int/healthinfo/systems/sage/en Health

426 International Trends in Geropsychology

Exhibit 16.2 Selection of Centenarian Studies

Danish Centenarian Registry http://www.sdu.dk/en/om_sdu/institutter_centre/ist_sundhedstjenesteforsk/ forskning/forskningsenheder/epidemiologi/forskningsprojekter/aging/oldestold/ centreg Fordham Centenarian Study http://www.fordham.edu/academics/programs_at_fordham_/psychology_departmen/ people/faculty/daniela_jopp/adult_development_an/centenarian_study/ Georgia Centenarian Study http://www.publichealth.uga.edu/geron/research/centenarian-study Korean Centenarian Study Park (2002) New England Centenarian Study http://www.bumc.bu.edu/centenarian Okinawa Centenarian Study http://www.okicent.org/study.html Sydney Centenarian Study http://cheba.unsw.edu.au/project/sydney-centenarian-study

aspects of diagnostic approaches, clinical service and in Australian research such perceived control delivery, or even national welfare systems. Examples over aspects of retirement has been related to satis- of the first two would include variations by country faction in retirement (De Vaus, Wells, Kendig, & in the usage of the American Psychiatric Associa- Quine, 2007). In fact, in an interesting international tion’s (2013) Diagnostic and Statistical Manual of study, early retirement has been proposed as a risk Mental Disorders, Fifth edition, WHO’s (2010) factor for cognitive decline in later life (Rohwed- International Classification of Diseases, 10th Edition, der & Willis, 2010). For a comparison of cognitive or the degree to which psychological services are functioning by retirement age in men and women covered by public versus private insurance and pub- ages 60 to 64 from this work, see Figure 16.3. licly funded schemes in various countries around Cross-national comparisons of health and the world. well-being also benefit from the existence of large Societal responses to aging also differ, and these national datasets and can usefully inform policy and differences can prove useful for cross-national practice. For example, data from the Health and research. One example is the issue of retirement in Retirement Study (United States), the English Lon- the face of increasing longevity. Both the average age gitudinal Study of Ageing (United Kingdom), and of retirement from full-time paid employment and the Survey of Health, Ageing and Retirement in what people expect and are expected to do after Europe (European Union) were examined with retirement vary widely across countries. For exam- respect to health outcomes (Avendano, Glymour, ple, the statutory age of retirement in Germany is Banks, & Mackenbach, 2009). In this study, Ameri- 65 for both men and women; in the United King- can adults reported worse health than did European dom, it is 65 for men and 60 for women (Economic adults as indicated by the presence of chronic dis- and Financial Affairs Directorate General & the ease and by measures of (WHO, 2011). European Commission, 2009). Given that these are Avendano et al. (2009) also reported that this was

Copyright American Psychological Association. Not for further distribution. statutory (i.e., mandated) retirement ages, in general true regardless of the level of affluence in the U.S. the expectation in these countries is that people do cohort; Americans’ health status was lower than that not work after this age. In Australia and New Zea- of Europeans at a similar level of wealth. Finally, land, however, a mandated age of retirement has they noted that in their sample, health disparities by given way to a legal change whereby forced retire- wealth were less prominent among Europeans than ment at a certain age is in almost all cases illegal. among Americans. These authors suggested that In these countries, the data reflect a wide variety of explanations for the noted health disparities responses to this change. For example, in Australia included differences in the health care systems and some older retirees withdraw pension funds to the social policy contexts in the United States and invest in so-called “self-funded retirement schemes,” Europe. For example, in the United States major

427 Nancy A. Pachana

12

United States England Denmark 10 Sweden Germany Switzerland Score Netherlands Austria

ve Belgium Greece 8 France Italy

erage Cogniti Slope: −4.9 Spain

Av 6

4 30 40 50 60 70 80 90 100 Percent Not Working for Pay

Figure 16.3. Cognition by percentage not working for pay, 60- to 64-year-old men and women, weighted. From “Mental Retirement,” by S. Rohwedder and R. J. Willis, 2010, Journal of Economic Perspectives, 24, p. 131. Copyright 2010 by the American Economic Association. Reprinted with permission.

adverse health events can lead to significant outlays Dementia Care of money, partly because uninsured and underin- One of the great challenges worldwide, as has sured people use up available funds to help cover already been noted, is meeting the demands of peo- medical expenses (Lee & Kim, 2003). Universal ple with dementia and their caregivers. Dementia is access to health care in Europe, in contrast, may currently the main cause of dependency in older substantially lower the need for such financial out- adults, and the health care costs associated with lays with respect to health care (Hurd, 2003). dementia in 2010 were estimated at $604 billion (Alzheimer’s Disease International, 2009). Thus, innovative health care delivery to this sector is of INNOVATIONS IN MENTAL HEALTH great importance. SERVICE FOR OLDER ADULTS Dementia care differs across countries (Moise, A systematic review of models or modes of delivery Schwarzinger, & Um, 2004). A systematic review of mental health care for older adults is beyond the of international consensus documents and existing scope of this chapter; interested readers are directed guidelines for long-term care (Gibson, Carter, to various global reports available from the UN and Helmes, & Edberg, 2010) found overarching agree- Copyright American Psychological Association. Not for further distribution. WHO websites and also to a broader comparison of ment on three broad principles for such care: health care structures in selected countries by the (a) should be located within a con- Economist Intelligence Unit (2012). However, a tinuum of services accessible on the basis of need; number of innovative health care delivery approaches (b) an explicit focus in such facilities should be qual- have been developed in specific countries but have ity of care; and (c) quality of life for residents should the potential to or have since migrated to other be a primary objective. The degree to which such countries, with varying degrees of adaptation. aspirations can be fulfilled depends on how such A sample of these follows; key references across care is organized within countries. For example, the these broad areas are given when appropriate. WHO’s (2002b) report on dementia and long-term

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care noted that residential care provision to older psychologists. Each of these discipline-specific adults varies between countries in which such care specialists has received additional training in nurs- is in development on a countrywide scale (e.g., Mex- ing and practice; moreover, the three ico) or in accelerated development because of popu- disciplines work in concert not only to deliver care lation pressures (e.g., China) to countries in which but explicitly to support each other. For example, home health care for such people is part of primary part of the role of the psychologist in health care delivery systems (e.g., Costa Rica and long-term care facilities is to support the other pro- South Korea). In Australia, the federal government fessions in their own handling of difficulties arising has allocated significant funding and workforce from care management. resources to assistance of people with dementia in both residential and community care through the Geriatric Mental Health Care in the provision of outreach services such as the Dementia Face of Rapidly Aging Populations Behavioural Management and Advisory Services, In countries such as China, mental health service which provide expert consultation at no cost to provision for older adults is in its infancy, yet the caregivers (Byrne & Neville, 2010). country is faced with the demographic reality of an Innovative dementia care initiatives have come aging population. The UN Department of Economic from several international quarters. The small-group and Social Affairs (2011) has estimated that China’s nursing home care approach that first started in aging population (people older than age 60) will Scandinavia (Malmberg & Zarit, 1993) and in the account for one third of its national population by Netherlands is relatively well known for its empha- 2050. China faces issues beyond the increasing pro- sis on person-centered care and a more normalized, portion of its population that is aging. For example, homelike environment for smaller groups of patients the migration of people from rural to urban areas with dementia compared with more traditional means that systems of financial, social, and instru- nursing homes (e.g., te Boekhorst, Depla, de Lange, mental support may become less robust for older Pot, & Eefsting, 2009). Small-group nursing homes adults living in rural and regional areas (Giles, have been shown to have a positive impact on Wang, & Zhao, 2010). China’s one-child policy patients, their families, and care staff (te Boekhorst, has also had an impact on social support for older Willemse, Depla, Eefsting, & Pot, 2008). The imple- people later in life. For example, if two only chil- mentation of such small-group homes has been dren marry, they are likely to take care of four par- taken up in other countries, including the United ents and eight grandparents, without siblings to States, and may prove an especially good option for help share the responsibility (Zhang, Guo, & people with intellectual disability who develop Zheng, 2012). dementia (Janicki, 2011). Interestingly, calls for In 2006 in China, a nongovernmental organiza- such small-group homes for care of older people in tion, Cun Cao Chun Hui, was established with the United States appeared relatively early (Oltman, the brief of providing services for psychological 1981). Other client-centered, homelike models have well-being for older people in Beijing (Wang & been developed, including the Eden and more recent Xianmin, 2014), the first nongovernmental organiza- Green House nursing home models (Lum, Kane, tion in that country dedicated to promoting older peo- Copyright American Psychological Association. Not for further distribution. Cutler, & Yu, 2008). ple’s mental health. The Cun Cao Chun Hui provides Aside from the benefits of such innovations in five main services to its target population: a hotline for nursing home care systems, of interest for the field psychological counseling; home visits for older peo- of clinical geropsychology, however, is the under­ ple, especially those living alone; public lectures on lying structure of nursing home clinical manage- mental health to older community-dwelling older ment in the Netherlands. In that country, nursing people (e.g., on memory decline, filial piety, and the home clinical management is headed by a triumvi- mental health care of old parents and grandparent- rate of specially trained clinical staff: nursing home ing); and individual and group psychological coun- physicians, nursing home nurses, and nursing home seling for older people (Wang & Xianmin, 2014).

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This endeavor, as is true in many Asian countries, is from the spirituality of the . This research supported by the government and indeed requires a has implications for the utility of providing spiritual high degree of cooperation and buy-in by the gov- support to such dyads in the caregiving journey, of ernment, service providers, and target populations. particular importance in South Korean society given Currently, government agencies remain the largest the reliance on familial caregiving models. This funders of research in China; in addition, govern- research may also speak to issues relevant for migrant ment agencies such as the China National Commit- populations of older people of South Korean descent. tee on Aging both guide and participate in aging research (Zhang et al., 2012). The increasing devel- Aging in Indigenous Peoples opment of such age-related health and mental health Aging research on indigenous populations is care services in China will increase the need for both increasingly incorporating mental health aspects in researchers able to evaluate service delivery and addition to the study of physical health outcomes. trained geriatric practitioners, including geropsy- Indigenous peoples make up about 6% of the chologists, able to deliver such services to a growing world’s population, consisting of approximately population of older adults with mental health needs. 5,000 groups spread across at least 70 countries South Korea has the fastest growing aging popu- (Horton, 2006). Older adults within the Aboriginal lation in the world as a result of the twin influences populations of several countries constitute a of increased longevity and a decreased birth rate fast-growing, understudied, and underserved popu- (Japan International Cooperation Agency, 2006). lation, with longevity estimates that lag behind non- The Confucian traditions of filial piety and familism indigenous populations in their countries. For remain strong in South Korea, as in many Asian example, in Canada Aboriginal adults older than age countries—witness the popularity in South Korea of 55 are the fastest growing population (Statistics Parent’s Day, an official holiday in South Korea Canada, 2010); in Australia in the period since 1973 (it is celebrated on the 8th of May). 2005–2007, the life expectancy at birth for indige- The central element of filial piety is respect and nous males was estimated at 67.2 years and for care for one’s parents (Sung, 1995). indigenous females at 72.9 years, well below the However, the concepts of filial piety are more Australian general population longevity estimates complex and multilayered; as a basis for develop- for men (78.5) and women (82.4; Australian Bureau ment of better measures of filial piety, Sung (1995) of Statistics, 2010). undertook to extrapolate key categories within the Dementia is the most common age-related cogni- construct of filial piety (see Exhibit 16.3). The tradi- tive condition among Aboriginal peoples (Bennett, tion of filial piety has influenced South Korean views 2008). Research on indigenous populations is on aging and care for aging adults—for example, the required if psychological assessment and treatment reluctance of younger people to place aging parents approaches are to be culturally sensitive and appro- in long-term care facilities (H. Kim & Choi, 2008). priate, as well as effective and accurate. The need for However, the constraints of a rapidly aging popula- such culturally specific tools and approaches is cer- tion and increased longevity have caused a rethink- tainly acute in older Aboriginal populations, as is ing of, as well as research into, elements of filial the need for an understanding of indigenous con- Copyright American Psychological Association. Not for further distribution. piety with respect to care of older adults in South ceptions of aging and age-related illnesses and Korea. For example, S.-S. Kim, Reed, Hayward, issues. Culture has the potential to shape test perfor- Kang, and Koenig (2011) published a model of fam- mance and should inform the development and ily spiritual–psychological well-being, describing the administration of tests, including neuropsychologi- influence of spirituality on psychological well-being cal tests (Manly, 2006). The results and interpreta- for both caregivers and care recipients in a family tion of cognitive testing also need to have ecological caregiving context. In their study of caregiver–care validity with respect to an individual’s life circum- recipient dyads, the care recipient was a particular stances (Teng & Manly, 2005); this would include beneficiary of support for psychological well-being cultural contexts.

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non-Aboriginal Australians in terms of health, life Exhibit 16.3 expectancy, and living circumstances. For Australian Categories of Filial Piety (Sung, 1995) Aboriginal people, life expectancy is more than 15 years lower, infant mortality is 3 times higher, rates 1. Love and affection of psychological distress and certain health conditions 2. Repayment and reciprocity 3. Family harmony (such as diabetes) are significantly higher, and income 4. Respect for parents is barely half that of non-Aboriginal Australians 5. Obligation and responsibility (Anderson et al., 2006; Australian Indigenous Health 6. Sacrifice for parents InfoNet, 2013). Although certain aspects of health care and morbidity have improved over the past 20 years, Australia’s indigenous population has not In Canada, Lanting, Crossley, Morgan, and Cam- closed health and welfare gaps in relation to the majority mer (2011) conducted a qualitative study on Aborig- population to the extent that other indigenous popula- inal conceptions of dementia and cognitive decline tions have elsewhere in the world (Ring & Brown, 2003). with a view to informing test development and Rates of dementia have been shown to be sub- assessment approaches with this population. Inter- stantially higher among indigenous than among views with an Aboriginal grandmothers group in the nonindigenous Australians (Smith et al., 2008). In province of Saskatchewan revealed similarities to and Smith et al.’s (2008) study, the rate quoted is 12.4%, differences from the non-Aboriginal population with with cause of dementia unspecified. This study was respect to conceptualizations of dementia. The cogni- conducted in the Kimberly region of Western Aus- tive decline and changed behaviors in this study tralia, the largest state in Australia, bordering the were identified as part of normal aging by partici- Pacific Ocean. To illustrate the nature of both the pants, similar to findings from other cultures regard- region and the difficulties in conducting such ing dementia as a regression to a state similar to research in this area, a few statistics may be of inter- childhood (Hinton & Levkoff, 1999). The persis- est. The Kimberly region, a beautiful and remote tence of negative impacts of changes to traditional area, makes up an area larger than the state of Cali- lifestyles and barriers to accessing health care were fornia, with a population of approximately 25,000 highlighted in the Lanting et al. (2011) study. The people, and only three towns have more than 2,000 consultative process led to the adaptation of the people living in them. About half of the population Pyramids and Palm Trees Test (Howard & Patterson, is indigenous, with a mean age of just older than 1992) to a Grasshoppers and Geese Test (Lanting, 20 years; only just more than 2,000 people are older Crossley, & Morgan, 2007), incorporating more famil- than age 45, and half of this group has received no iar color photos as more culturally relevant stimuli. formal education (Bennett, 2008). There are about Similar issues regarding the need to both better 200 Aboriginal communities in this area, with nearly understand indigenous conceptions of dementia and 40 spoken languages. It is very difficult, to say the to create more culturally relevant assessment tools least, to provide health care services in such a have arisen in Australia. Aboriginal Australians repre- region, let alone conduct epidemiological research. sent 2.5% of the Australian population; the number of As stated, Smith et al. (2008) found a rate of Copyright American Psychological Association. Not for further distribution. older indigenous people age 55 and older is pro- dementia of 12.4% for the general Australian popula- jected to more than double over the next 20 years, tion age 45 and older (Australian Institute of Health from 40,000 individuals in 2006 to between 82,000 and Welfare, 2006). In their study, 363 indigenous and 86,600 individuals in 2021 (Australian Bureau of people (55% women) older than age 45 (range = Statistics, 2009). (In contrast, for example, according 45–96) from the Kimberly region were interviewed to the U.S. Census Bureau [2003], the United States by indigenous people trained in the use of the Kim- has about 4.3 million indigenous people, representing berley Indigenous Cognitive Assessment (LoGiudice less than 2% of the population.) There is a significant et al., 2006; see Exhibit 16.4). This assessment was distance between the expectations of Aboriginal and developed and validated in the Kimberly region, with

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Exhibit 16.4 The projected estimated needs for mental health Selected Items From the Kimberley Indigenous specialists in general and geropsychologists in Cognitive Assessment (LoGiudice et al., 2006) particular has been a concern for many years (Karel, Gatz, & Smyer, 2012; Knight, Karel, Hinrichsen, 1. Orientation item: What time of year is it? (prompt for wet Qualls, & Duffy, 2009). For example, in a relatively time/dry time, hot time/cold time) recent survey, 4.2% of licensed health services pro- 2. Verbal comprehension: Point to the sky, then point to the viders in the American Psychological Association ground (APA; 2008) identified geropsychology as an area 3. Verbal fluency: Tell me the names of all the animals that people hunt of current focus for work; 39% overall reported that 4. From depression self-report scale: Do you feel grumpy? they provided at least some services to older adults (growling at people a lot) Do you reckon you are still during the most recent typical week of practice. thinking straight? This represents a small increase over figures from a 5. From the cognitive informant report questions: Does s/he do things that are wrong in the Aboriginal way (e.g., similar survey conducted in 1999, in which 3% of calling out names of people who have passed away)? licensed health services providers viewed geriatric patients as their primary professional target (Qualls, Segal, Norman, Niederehe, & Gallagher-Thompson, consultation and input from indigenous peoples and 2002). However, the degree to which psychologists indigenous mental health workers. It was designed work with older adults differs widely. In contrast to to assess cognitive function as well as information the U.S. data presented, in a recent large survey of about prior medical history, activities of daily living, psychologists practicing in Australia, average ratings and so forth from both a patient and an informant. of confidence in working with older adults were Because of differences in language across Aborigi- modest, and only 6% of psychologists surveyed nal groups in Australia, and also to take into account specialized in working with older adults (Koder & aspects of cultural safety and practice that vary by Helmes, 2008). In this survey, approximately 40% group, using an assessment tool such as the Kimber- of psychologists reported no contact at all with older ley Indigenous Cognitive Assessment is not straight- adults in their practice. forward. For example, as part of a naming test, if an To some extent, the number of geriatric special- animal is depicted that cannot be spoken about by ists is reflective of training opportunities. To con- that particular individual for cultural reasons, then tinue the contrast between the United States and substitute stimuli must be provided. Interviewers Australia, the 2011 U.S. Association of Psychology gathering information need to be sensitive to cultural Postdoctoral and Internship Centers directory listed issues, particularly issues related to gender (e.g., 86 accredited internship programs in the United men’s and women’s business) and to people who have States that provide a major rotation in geropsychol- passed away (there are specific and time-delimited ogy and 223 programs offering a minor rotation in ways in which such people can be referred to). geropsychology, out of a total 670 such programs Unfortunately, little information for psychologists currently offered. Of 36 clinical psychology training working with Aboriginal people exists in the form of programs in Australia, only two offer specialization published resources (see Mckelvie & Mallard, 2000, in clinical geropsychology. Copyright American Psychological Association. Not for further distribution. as one example of such a practical resource), but Training in geropsychology should include both little in the way of geropsychology resources exist. research and clinical training. Barriers limiting train- ing in either research or clinical skills in geropsy- chology include the failure of training programs to WORKFORCE AND TRAINING ISSUES IN provide adequate didactic content as well as suitable GEROPSYCHOLOGY INTERNATIONALLY clinical placement opportunities. In a cross-national As mentioned previously, the overall geriatric health study of clinical geropsychology content across and mental health workforce will fall far short of three countries (United States, Australia, Canada), a needs in the future, given global demographic shifts. minority of programs were shown to provide strong

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leadership in the aging area (Pachana, Emery, Kon- practices. The many accredited field placement nert, Woodhead, & Edelstein, 2010). Others (nota- settings available in the United States would be the bly Whitbourne & Cavanaugh, 2003) have written envy of many other countries. In Portugal, for exam- eloquently about the danger of not incorporating ple, the workforce situation for geropsychologists is aging into the undergraduate curriculum (and this constrained by the lack of education and training would apply to all disciplines, not just psychology) opportunities in the psychology of later life in most in terms of failing to stimulate student interest in of the universities in that country and, in particular, aging more generally. the lack of opportunities to become specialized Without adequate exposure to older adults, psy- in geropsychology (Ribeiro, Fernandes, Firmino, chology students may not think to choose aging as Simões, & Paúl, 2010). A limited geropsychology an area of interest, whatever particular subdisci- presence in the clinical workforce also has a nega- plinary area of psychology they may ultimately pur- tive impact on supervision opportunities and there- sue. Other barriers may also prevent students from fore on the competency acquisition and capability pursuing careers involving older adults. A recent of the nonspecialized clinical psychology workforce cross-disciplinary study (Gonçalves et al., 2011) who will find themselves increasingly in contact found that nursing and social work students dis- with older adults. This flow-on effect is worthy of played more positive attitudes, knowledge, and study in its own right. interest in working with older adults than psychol- Training in geropsychology for work with partic- ogy students. A regression analysis on the data indi- ular populations within geriatrics is also of concern. cated that attitudes, knowledge, and previous formal One such population is older people living in nurs- contact with older adults were significant predictors ing homes. There are not enough clinical psycholo- of interest in working in geriatric settings. gists with particular training and expertise in Furthermore, biases in the treatment of older working in long-term care settings (Molinari & adults have been documented in the literature. For Edelstein, 2011). The role of training of psycholo- example, Helmes and Gee (2003) investigated the gists in nursing home care is important because peo- attitudes of Australian therapists toward older clients ple with dementia can challenge workers, and such through a postal survey of 707 psychologists and patients tend to bring out ageist tendencies even in counselors. Participants in the study received a case those who do not normally espouse such sentiments vignette indicative of depression, noting that the (Gatz & Pearson, 1988). In an interesting piece, White woman described was either 42 or 72 years of Lomranz and Bar-Tur (2001) provided a description age. The participants were asked to indicate their of what clinical geropsychology services in a nursing opinion on the client’s presenting problem, progno- home environment might look like, including the sis, and appropriateness for therapy. They were also potential to forge links with university training pro- asked to rate their ability to develop an adequate grams and clinics. Such links would not only help to therapeutic relationship with the client and their encourage students to look at a career in aging and perceived level of competence in treating and will- perhaps nursing home care in a new light but also ingness to accept her as a client. Results indicated might assist with the flow of knowledge from the that although the client was correctly diagnosed university and its research resources to long-term Copyright American Psychological Association. Not for further distribution. regardless of her age in an average of 90% of cases, care settings. In my university, a memorandum of the older client was rated as less able to develop an understanding setting out shared goals with respect adequate therapeutic relationship, to have a poorer to research and clinical practice between Alzheim- prognosis, and to be less appropriate for therapy er’s Australia (Queensland) and the University of than the younger client. Therapists in the study also Queensland has led to important research collabora- indicated that they felt less competent in treating her tions, many student research projects, much valued and less willing to accept her as a client. access to the university’s library holdings including One way to combat ageist attitudes is via expo- journal access, and the opportunity to consider joint sure. Another is through mentoring and supervision bids for tenders and other health service contracts.

433 Nancy A. Pachana

As Lomranz and Bar-Tur pointed out, the goal of a Exhibit 16.5 geropsychologist in a care setting for older adults is Geropsychology Peak Organizations to “actualize potential” (p. 495); the same could be Internationally said more broadly for educational institutions and peak bodies involved in geropsychology training I. North America and practice. A. GeroCentral (http://gerocentral.org) A final workforce setting of note is universities, B. APA Division 12, Section II, Society of Clinical in which both future clinicians and researchers are Geropsychology (http://www.geropsychology.org) trained (at least in many countries). Although avail- C. Psychologists in Long-Term Care (http://www. pltcweb.org/index.php) able numbers are scarce, Portugal, for example, fol- II. Europe lows the general trend observed in geropsychology A. European Federation of Psychologists’ Associations, in Europe, in which, in general, research on aging is Standing Committee on GeroPsychology (http://geropsychology.efpa.eu) more developed than the field of clinical geropsy- III. Australia and New Zealand chology (Pinquart, 2007). Differences between A. Australian Psychological Society, Psychology European countries are large, but there is an overall and Ageing Interest Group (http://www.groups. lack of investment in this area, population demo- psychology.org.au/paig) B. New Zealand Psychologists of Older People graphics notwithstanding. According to Pinquart (http://nzpops.co.nz) (2007), the average number of full professors in Note. Currently, such cross-national peak bodies spe- geropsychology in the European countries surveyed cifically for geropsychology do not exist in Asia or was 2.3 per country, and the mean number of gero- South America, although individual countries in these psychologists in each was 146. These figures, regions often have geropsychology-specific interest groups or associations. according to Pinquart, in part motivated the Euro- pean Federation of Psychologists’ Associations to launch a task force on geropsychology. This Stand- ing Committee on GeroPsychology recently filed its example of such an international educational effort report on geropsychology activities and future plans, was the European Masters Program in Gerontology, which include an expert database of geropsychology which until recently was funded by the European across European Union member states, as well as Commission (Heijke, 2004). Developed and deliv- guidelines, recommendations, and suggestions ered by a network of 20 European universities, the related to standards in geropsychological studies European Masters Program in Gerontology helped and master’s programs and a position paper about to train dozens of young European gerontologists. the importance of geropsychology in nursing and Its strong emphasis on cross-national comparisons resident homes as well as general hospitals across of data and its policy of various European universi- Europe (European Federation of Psychologists’ ties hosting modules of content meant its graduates Association, 2013). truly had an international view of aging research, The report of the Standing Committee on Gero- practice, and policy. Unfortunately, the global finan- Psychology to the European Federation of Psycholo- cial crisis and its aftermath ended this program. gists’ Associations made particular mention of the In 2006, a U.S. National Conference on Training Copyright American Psychological Association. Not for further distribution. costs of meetings and noted that this was a hin- in Professional Geropsychology led to the develop- drance to the activities of the committee. Despite the ment of the Pikes Peak model for geropsychology growth of geropsychology as a discipline interna- training (Knight et al., 2009) as well as the establish- tionally, there remain areas of expertise and areas in ment of the Council of Professional Geropsychology which there is a dearth of geropsychology experts Training Programs (http://www.uccs.edu/~cpgtp). globally (see Exhibit 16.5). This situation affects This council serves an important role in forging research somewhat, but researchers appear to be links between training institutions with a focus on bridging these geographical distances; international geropsychology; membership of this group is open conferences assist this cause greatly. An excellent to non-U.S. institutions. In the future, this group

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could help assist with cross-national geropsychology familiar with the international landscape of clinical educational initiatives; it has already funded via geropsychology practice overseas. Membership in small grants cross-national research projects looking international organizations concerned with global at geropsychology training and competencies (e.g., aging and mental health can offer connections, Pachana et al., 2010; Woodhead et al., 2013). employment opportunities, and avenues to serve on Expertise in teaching and training in geropsy- committees and task forces with international agen- chology internationally would benefit from such das. Finally, no matter what the country or setting, a links, even across continents and hemispheres, but geropsychologist is likely to come into contact with costs are prohibitive. Yet researchers in a variety of patients, colleagues, and peers who hail from other gerontology, geriatrics, and geropsychology pro- places; some understanding of potential differences, grams (myself included) are using Skype and other even to acknowledge the lack of knowledge of forms of web-based conferencing and teaching plat- potential differences, could be useful. forms to build e-bridges to expertise and shared As Knight (2011) commented in his article on understanding. Such approaches are now being eval- the mentoring process in a special issue of Educa- uated in the literature (e.g., Majeski & Stover, 2007). tional Gerontology on mentoring, “Helping students An extension of such training initiatives could be develop a broader sense of options and roles is a key online mentoring. In 2011, an entire issue of Educa- goal of mentoring. There are wide ranges of settings tional Gerontology was devoted to mentoring in gero- both within the academic world and within clinical psychology for both practitioners and researchers, practice” (p. 385). I would only add that this range highlighting a number of issues that are relevant in includes international options and opportunities. an international context. The Council of Professional Geropsychology Training Programs itself offers an FUTURE DIRECTIONS FOR informal mentoring program for institutions or for GEROPSYCHOLOGY INTERNATIONALLY individuals (e.g., postlicensure psychologists) who are interested in guidance in expanding their exper- Obviously, geropsychologists will need to continue tise with older adults. Mentors do more than teach to contribute to research across a wide range of top- and supervise—they have the potential to inspire ics in aging. With respect to clinical geropsychology, and provide support to future generations of gero- diagnosis, assessment and treatment of health and psychologists (Zimmerman, Fiske, & Scogin, 2011). mental health disorders in later life, health care Such mentors have the capacity to introduce new delivery, and policy issues are obvious choices. and potential geropsychologists to the entire range In Europe, where geropsychology is often conceptu- of the field, including its international components. alized much more broadly (Fernandes-Balesteros, Attendance overseas at an international conference 2008), prevention and promotion of healthy aging, can help forge future research links and broaden work and retirement issues, and education were perspectives on how geropsychology and even clini- most frequently mentioned by respondents in a large cal psychology itself is practiced in different parts of cross-national survey as requiring further research the world. In academic careers, promotion and ten- focus (Pinquart, 2007). In Australia, recent attention ure applicants increasingly need to show some evi- has focused on geropsychology in the older adult Copyright American Psychological Association. Not for further distribution. dence of international recognition and collaboration. care sector, with calls for increasing attention to the Likewise, faculty in university settings increasingly topic as part of clinical psychology training pro- include international colleagues who may have a grams (Pachana, 2008). In Asia, geropsychology is great deal to offer their colleagues and students but growing in importance in the research arena but who may also need help adjusting to a new environ- requires greater emphasis on incorporating aging ment. Students in programs may be interested in into the curriculum, at both the undergraduate and jobs overseas; such jobs may offer unique profes- the graduate levels (Pachana, 2012). sional and personal development opportunities but Aging as a process involves many more systems than may seem out of reach to people without advisors simply the psychological, and thus geropsychology

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must forge interdisciplinary connections across a pas (Kitayama & Karasawa, 1995). In a further vast array of disciplines (Lehr, Re, & Wilbers, exploration of the positivity effect in an Asian con- 2007). Interdisciplinary research and practice are text, Fung, Isaacowitz, Lu, and Li (2010) found that often discussed and perhaps in teaching are more the age-related positivity effect was not as strong formally developed with respect to strategies among more highly interdependent older Chinese (Steffen, Zeiss, & Karel, in press). Interdisciplinary individuals as among those who were less interde- research collaborations in the future may include pendent. Again, culture plays a role in how and why joint efforts between geropsychology and disciplines older individuals react to stimuli. In the years ahead, still in development (e.g., behavioral genetics). Lehr one might expect many such theories to be tested in et al. (2007) pointed out that aging represents chal- a variety of cultures, and their results will help to lenges for policymakers and politicians, as well as deepen knowledge of cross-cultural geropsychology. scientists and educators, and also for older people themselves, and again links here are useful. In Asian CONCLUSIONS countries, as has been mentioned, links between government and research bodies often assist in It is interesting to reflect on international issues as bringing programs to fruition; this is not as common they affect geropsychological theory and practice. in Western societies, and the potential inherent in The world continues to grow smaller and yet more such partnerships could be usefully explored. complex over time. Technological, health care, and Finally, many of the constructs underpinning social changes are just a few of the many forces driv- key aspects of geropsychology theory and practice ing change in how we perceive our work and our may have different meanings or expression in differ- world. Nevertheless, some things have still not ent cultures. In a recent study by Matsubayashi, changed (e.g., more trained clinical geropsycholo- Masayuki, Wada, and Okumiya (2006), partici- gists are needed to meet the future health care pants in Japan and the United States were asked to demands of an aging population than are currently indicate among 20 attributes those that defined being produced). successful aging for them. Interestingly, 75% of the It is easy to stop seeing the forest for the trees, attributes rated as important by American respon- whether you conceive of the forest as the interna- dents (both Japanese Americans and Americans not tional or sometimes even the national landscape. of Japanese descent) were not rated as important by Local issues and demands can narrow perspectives, 75% of the Japanese respondents in the study. perhaps necessary for short periods but ultimately Thus, the results of this study suggested that differ- unproductive in the long term. ent cultures have different understandings of suc- Being able to step back and view the broadest cessful aging. possible landscape in a discipline is important if Similarly, Fung et al. (2008) have undertaken to we want to build a strong and global response to examine Carstensen and Mikels’ (2005) positivity the needs of the aging population worldwide. Join- effect in an Asian population. In a series of studies, ing forces across nations can strengthen research this group has shown that older adults in Hong and practice initiatives, broaden the knowledge Kong do not demonstrate preferential cognitive pro- base, and help drive innovation in the field. Stu- Copyright American Psychological Association. Not for further distribution. cessing of positively valenced relative to negatively dents and young professionals will increasingly valenced stimuli, in contrast to findings in Western have to operate in a global environment, and talk- samples (Fung et al., 2008). Fung et al. (2008) had ing in international terms early on helps keep hypothesized that people operating in cultural con- horizons broad. In this chapter, I have only texts that attach less importance to positive emo- touched on selected topics and issues in geropsy- tions might not show the same effects. They posited chology from an international perspective, in an that in cultures such as Japan and China, the desire attempt not to be systematic or complete but to to fit into social contexts motivates individuals to be stimulate further exploration and thinking about attuned to negative emotions to avoid social faux the field in a global context.

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Appendix 16.1. United Nations 14. utilize appropriate levels of institutional care Principles for Older People that provide protection, rehabilitation, and social and mental stimulation in a humane and secure environment; and INDEPENDENCE 15. exercise human rights and fundamental free- Older people have the right to doms when residing in any shelter, care, and 1. access to adequate food, water, shelter, clothing, treatment facility, including full respect for and health care through the provision of income, their dignity, beliefs, needs, and privacy and for family and community support, and help; the right to make decisions about their care and 2. work and pursue other income-generating quality of life. opportunities with no barriers based on age; 3. retire and participate in determining when and SELF-FULFILLMENT at what pace withdrawal from the labor force Older people have the right to takes place; 16. pursue opportunities for the full development of 4. access education and training programs to their potential and enhance literacy, facilitate employment, and 17. access the educational, cultural, spiritual, and permit informed planning and decision making; recreational resources of society. 5. live in environments that are safe and adaptable to personal preferences and changing capacities; DIGNITY and Older people have the right to 6. reside at home as long as possible. 18. be treated fairly regardless of age, gender, racial PARTICIPATION or ethnic background, disability, or other status Older people have the right to and to be valued independently of their eco- nomic contributions; 7. remain integrated and participate actively in 19. live in dignity and security and to be free society, including the development, formu- of exploitation and physical or mental lation, and implementation of policies that abuse; and directly affect their well-being; 20. exercise personal autonomy in health care deci- 8. share their knowledge, skills, values, and life sion making, including the right to die with experiences with younger generations; dignity by assenting to or rejecting treatment 9. seek and develop opportunities for service to the designed solely to prolong life. community and to serve as volunteers in posi- tions; and Note. From Principles for Older Persons, 1991, New 10. form movements or associations of older adults. York, NY: United Nations. Copyright 1991 by the United Nations. Reprinted with permission. CARE Older people have the right to

Copyright American Psychological Association. Not for further distribution. References 11. benefit from family support and care consistent Aichberger, M. C., Schouler-Ocak, M., Mundt, A., with the well-being of the family; Busch, M. A., Nickels, E., Heimann, H. M., . . . Rapp, 12. access health care to help them maintain or M. A. (2010). Depression in middle-aged and older regain the optimum level of physical, mental, first generation migrants in Europe: Results from and emotional well-being and to prevent or the Survey of Health, Ageing and Retirement in Europe (SHARE). European Psychiatry, 25, 468–475. delay the onset of illness; doi:10.1016/j.eurpsy.2009.11.009 13. access social and legal services to enhance Alzheimer’s Disease International. (2009). World Alzheimer’s capacity for autonomy and provide protection report, 2009: Global prevalence and impact of demen- and care; tia. London, England: Author.

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